diabetes and tuberculosis, an unholy alliance
TRANSCRIPT
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Diabetes and Tuberculosis: an unholy alliance
Dr. Mohammad Tanvir IslamAssistant Professor, MedicineBangabandhu Sheikh Mujib Medical University
Dr. Shamim AhmedAssistant Professor, RespiratoryMedicineBangabandhu Sheikh Mujib Medical University
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Background Epidemiology 347 million people worldwide have
diabetes 80% diabetes deaths in low- and
middle-income countries 7th leading cause of death in 2030 In Bangladesh between 2% and 21%
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Diabetes 2013
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Projected prevalence of DM in 2030
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Tuberculosis around the world
About 9 million people around the world
A total of 1.5 million people died in 2013
The incidence of TB in Bangladesh is 225 per 100,000
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Worldwide Tuberculosis
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High burden TB countries
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ChinaIndiaBrazilBangladeshIndonesiaPakistanRussia
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Intersecting Epidemics
Big concern about twin epidemics Low to middle income countries DM increases the risk of TB 3 fold TB causes glucose intolerance
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Association between diabetes and active tuberculosis in studies stratifying by glucose control
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14.8% of PTB & 20.2% smear positive PTB cases are directly linked to DM
TB causes glucose intolerance 50 % of which normalizes after ATT
DM increases risk of TB 3 times TB increases risk of DM 2 times
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Historical aspects
Since ancient times Susruta in 600 AD Avicenna (780-1027 AD) Roots 1950 Nicholas 1957 McCornick 2007
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Pathogenesis of tuberculosis
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Four possible outcomes: Immediate clearance of the organism Latent infection The onset of active disease (primary
disease) Active disease many years later
(reactivation disease).
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Persons with medical conditions that weaken the immune system
HIV infection Diabetes mellitus Medical treatments such as
corticosteroids or organ transplant Substance abuse Organ transplants Malignancy
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Pathophysiology Hyperglycemia favours growth , viability and
propagation of tubercle bacilli and hamper resistance to infection & repair capacity
Increased availability of glycerol and nitrogenous substances aid the growth of tubercle bacilli
High level of insulin have been shown to promote a decrease in Th1 immunity through a reduction in the Th1 cell to Th2 cell ration and interferon gamma to IL-4 ratio
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Immunologic abnormalities in Diabetes
Abnormal chemotaxis Decreased peripheral monocytes
with impaired phagocytosis Poor blast transformation of
lymphocytes Defective C3 opsonic function Decrease in Th1 immunity
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Pulmonary physiologic dysfunction in diabetes
Diminished bronchial reactivity Reduced diffusion capacity Occult mucous plugging of airways Reduced ventilatory response to
hypoxaemia
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Pathophysiologic dysfunction of lung in diabetes
Microangiopathic change in pulmonary vasculature
Non-enzymatic glycosylation of tissue protein
Thickening of epithelial and caplillary BM
Interference with clearance mechanism
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Increased risk of
tuberculosis
Diabetes
Neutrophil• Abnormal
Chemotaxis• Phagocytosis• Microbicidal acitvity
Reduction in Th1 cells
Interferon gamma
Increased availability of Glycerol and nitrogenous substances
Lung physiological and pathological
dysfunction
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Increased risk of Tuberculosis
Impairment ofInnate immunity Acquired immunity
DiabetesLung Physiologic dysfunction
Lung Pathologic dysfunction
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Impact of TB on glycaemic status
Relative and absolute overproduction of adrenocorticotropic hormone
Increased supply of corticosteroids Corticosteroids are insulin
antagonists resulting in insulin resistant diabetes.
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Clinical menifastations
More aggressive course Less clinical manifestations Typical features like cough, weight
loss are less prominent Prolonged duration of fever
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Clinical menifastations
Features of one disease can mimic the other
Might progress rapidly Flare up or spread of tuberculosis More complications Risk for Drug-resistant TB
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Comparison of clinical features
Clinical feature
DM & TB TB only
Fever 64% 98%Night sweat 52% 85%Cough>3wks 71% 96%Weight loss 69% 94%
Hossain D, Latif ZA, Mahtab H Clinical and radiological presentation of pulmonary Tuberculosis in diabetic and non-diabetic patients. J Soc Heart Chest Dis 2004;2:69-72
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Radiology of PTB in DM
Frequently atypical Lower lobe opacity Multilobar Cavitary lesion Pleural effusion
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Comparison of radiological features in TB patients with or without DM
Radiological feature
DM +TB TB alone
Upper lobe opacity 17% 56%Lower lobe opacity 19% 7%Multi lobe opacity 64% 36%Cavity 82% 59%
C.Perez et.al. 2001
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Radiology
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Summery
DM & TB prevalence is increasing They are epidemic in identical areas DM is a risk factor for TB TB causes glucose intolerance Clinical and radiological features in a
diabetic TB patient may be atypical
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